Value and the medical home: effects of transformed primary care.

BACKGROUND: The primary care medical home has been promoted to integrate and improve patient care while reducing healthcare spending, but with little formal study of the model or evidence of its efficacy. ProvenHealth Navigator (PHN), an intensive multidimensional medical home model that addresses care delivery and financing, was introduced into 11 different primary care practices. The goals were to improve the quality, efficiency, and patient experience of care. OBJECTIVE: To evaluate the ability of a medical home model to improve the efficiency of care for Medicare beneficiaries. STUDY DESIGN: Observational study using regression modeling based on preintervention and postintervention data and a propensity-selected control cohort. METHODS: Four years of claims data for Medicare patients at 11 intervention sites and 75 control groups were analyzed to compute hospital admission and readmission rates, and the total cost of care. Regression modeling was used to establish predicted rates and costs in the absence of the intervention. Actual results were compared with predicted results to compute changes attributable to the PHN model. RESULTS: ProvenHealth Navigator was associated with an 18% (P <.01) cumulative reduction in inpatient admissions and a 36% (P = .02) cumulative reduction in readmissions across the total population over the study period. CONCLUSIONS: Investing in the capabilities of primary care practices to serve as medical homes may increase healthcare value by improving the efficiency of care. This study demonstrates that the PHN model is capable of significantly reducing admissions and readmissions for Medicare Advantage members.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.

OBJECTIVE: To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. METHODS: The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). RESULTS: Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) CONCLUSION: A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.